Corrective Action Plans

Finding 569245 (2024-001)

Significant Deficiency 2024

OH

Subrecipient Monitoring Reporting Significant Deficiency § 200.328

Finding Number: 2024-001 : Significant Deficiency and Noncompliance - Reporting Planned Corrective Action: As recommended, Management will implement controls and processes to ensure all required reports are submitted timely. Anticipated Completion Date : June 30, 2025 Responsible Contact Person: Ra...

Finding Number: 2024-001 : Significant Deficiency and Noncompliance - Reporting Planned Corrective Action: As recommended, Management will implement controls and processes to ensure all required reports are submitted timely. Anticipated Completion Date : June 30, 2025 Responsible Contact Person: Randy Bartels, City Auditor

View Audit 360824

Finding 569138 (2024-001)

Significant Deficiency 2024

City of Plymouth

MN

Internal Control / Segregation of Duties Special Tests & Provisions Significant Deficiency

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT – HOUSING VOUCHER CLUSTER – FEDERAL ALN 14.871 AND 14.879 2024-001 Internal Control Over Compliance With Special Tests and Provisions Requirements Summary of Finding The City of Plymouth...

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT – HOUSING VOUCHER CLUSTER – FEDERAL ALN 14.871 AND 14.879 2024-001 Internal Control Over Compliance With Special Tests and Provisions Requirements Summary of Finding The City of Plymouth, Minnesota (the City) did not have sufficient controls in place with the Housing Voucher Cluster federal programs to assure compliance with federal special tests and provisions requirements. The City did not have proper controls in place to ensure prospective tenants added to the voucher waiting list were properly ranked based on the Housing and Redevelopment Authority approved criteria. Corrective Action Plan Actions Planned – The City has implemented new controls and procedures in 2025 to address this internal control finding to comply with this finding. The City will review new controls to ensure that prospective tenants are properly ranked on the waiting list in accordance with the Housing and Redevelopment Authority policy in the future. Official Responsible – The City’s Housing and Economic Development Manager. Planned Completion Date – December 31, 2025. Disagreement With or Explanation of Finding – The City agrees with this finding. Plan to Monitor – The City’s Finance Director, Andrea Rich, will ensure the new process and procedures implemented improve internal controls and procedures in this area to ensure future federal grant compliance.

View Audit 360720

Finding 569130 (2024-001)

Significant Deficiency 2024

Housing Authoirty of the City of Salem

OR

Questioned Costs Special Tests & Provisions HUD Housing Programs

Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Federal Catalog Numbers: 14.871. 14.879, and 14.EHV Noncompliance – N. Special Tests and Provisions - Housing Quality Standards Non Compliance Material to the Financial Statements: No Sig...

Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Federal Catalog Numbers: 14.871. 14.879, and 14.EHV Noncompliance – N. Special Tests and Provisions - Housing Quality Standards Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Special Tests and Provisions Criteria: HQS Inspections. Per the Authority's HCV Admin Plan, the PHA must inspect the unit leased to a family biennially in order to determine if the unit meets HQS standards, and the PHA must conduct quality control re-inspections. The PHA must prepare a unit inspection report (24 CFR sections 982.158(d) and 982.405(b)). These inspection reports are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority’s files and on discussion with management there were inspection reports that were not completed timely. Context: Of a sample size of thirty-nine (39) units, five (5) units did not have biennial HQS inspections performed timely. Our sample size is statistically valid. Known Questioned Costs: $4,214 Cause: There is a significant deficiency in internal controls over the compliance for the special tests and provisions type of compliance related to HQS inspections. The Authority has not properly performed HQS inspections in compliance with program requirements. Effect: The Housing Voucher Cluster is in non-compliance with the special tests and provisions type of compliance related to HQS inspections. Recommendation: We recommend the Authority design and implement a corrective action plan that will assure compliance with the Uniform Guidance and the compliance supplement. Authority Response: The Authority accepts the recommendation of the auditor and will make the necessary changes to its inspection process to ensure enforcement of Housing Quality Standards (or any subsequent replacement. Lynette Brown, Section 8 Manager, is responsible for implementing this corrective action by September 30, 2025.

View Audit 360717 Questioned Costs: $1

Finding 569128 (2024-004)

Significant Deficiency 2024

Housing Authority of the City and County of San Francisco

CA

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Reference Number: 2024-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: Section 8 Housing Choice Vouchers Federal Catalog Number: 14.871 Federal Grant Number: Not Applicable Category of Finding: Special Tests and Provisions – HQS Enforcement Classification ...

Reference Number: 2024-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: Section 8 Housing Choice Vouchers Federal Catalog Number: 14.871 Federal Grant Number: Not Applicable Category of Finding: Special Tests and Provisions – HQS Enforcement Classification of Finding: Significant Deficiency in Internal Control over Compliance Instance of Noncompliance Authority’s Response & Actions Taken The Authority has made considerable progress in addressing the backlog of annual Housing Quality Standards (HQS) inspections and enforcement since transitioning the programmatic functions of the Housing Choice Voucher (HCV) program to third-party contractors. While significant strides have been made, the Authority acknowledges that further progress is necessary and remains actively engaged with its third-party HCV contractors to ensure that all HCV-assisted units meet and consistently maintain HUD’s HQS requirements. The Authority remains committed to ensuring that all units under contract are not only compliant but provide safe, sanitary, and decent housing in accordance with HQS regulations and the Authority’s Administrative Plan. The discrepancies noted in the audit were primarily due to inconsistencies in the application of enforcement timelines and insufficient documentation related to landlord extension requests and their corresponding approvals. Importantly, all delayed follow-up inspections identified during the audit were successfully completed outside the required timeframes. Each unit passed inspection and was found to be compliant with HUD HQS standards. Housing assistance payments (HAP) were accurately processed for these units, and no abatements were necessary. The Authority continues to refine its inspection protocols, improve documentation practices, and reinforce contractor accountability to ensure timely and compliant HQS inspections across the entire HCV portfolio. The Authority uses the Emphasys Elite software to schedule, record, and enforce HQS inspections. The Authority also uses its Customer Relations Management (CRM) system to track units that have failed an HQS inspection. To prevent recurrence, the Authority has already implemented the following corrective steps: • Daily review process of units that have failed and/or no-showed two or more consecutive inspections. The inspection department uses this process to accurately review the letter generation and notification process for HQS deficiencies and notices of abatement. The inspection department manually reviews and generates both letters to their respective parties (landlord/owner and tenant). • In addition to the daily morning review, at the close of business the HCV contractor will review the failed emergency inspections and will schedule any emergency re-inspections to ensure compliance with HQS enforcement rules and regulations. The Authority’s corrective steps outlined above will significantly strengthen its compliance efforts, reduce risk, and enhance the overall quality and integrity of the HCV program. Anticipated Implementation Date September 30, 2025 Name(s) and Title(s) of Contact Person(s) Responsible for Correction Action HCV Contractors Kendra Crawford, Director of Housing Operations

View Audit 360716

Finding 569125 (2024-003)

Significant Deficiency 2024

Housing Authority of the City and County of San Francisco

CA

HUD Housing Programs Special Tests & Provisions Significant Deficiency

Reference Number: 2024-003 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: Housing Choice Cluster Federal Catalog Number: 14.871 and 14.879 Federal Grant Number: Not Applicable Category of Finding: Special Tests and Provisions (Housing Quality Standards Inspec...

Reference Number: 2024-003 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: Housing Choice Cluster Federal Catalog Number: 14.871 and 14.879 Federal Grant Number: Not Applicable Category of Finding: Special Tests and Provisions (Housing Quality Standards Inspections) Classification of Finding: Significant Deficiency in Internal Control over Compliance Instance of Noncompliance Authority’s Response & Actions Taken The Authority has made considerable progress in addressing the backlog of annual inspections that resulted from restricted unit access and the temporary implementation of HUD waivers during the COVID-19 national pandemic. These necessary public health measures, while appropriate at the time, contributed to delays in fulfilling Housing Quality Standards (HQS) inspection requirements. The Authority acknowledges that additional progress is still needed and remains actively engaged with its third-party Housing Choice Voucher (HCV) contractors to ensure timely completion of all outstanding inspections. The Authority is fully committed to ensuring that all units under contract meet and exceed HUD’s standards for safe, decent, and sanitary housing, in accordance with HQS and the Authority’s Administrative Plan. All five annual inspections with exceptions noted during the audit were inspected after the required timeframes and ultimately passed inspection with the units determined to be in full compliance with HUD requirements. The Authority uses the Emphasys Elite software to check against HUD's PIH Information Center (PIC) system to identify units with outstanding Housing Quality Standards (HQS) Inspections. The Authority has scheduled HQS Inspections for the units identified to be out of compliance. Key strategies and controls in place are as follows: Project-Based Program: For the PBV program, the Authority has already implemented the following procedures to result in timely HQS inspections of all units. 1. Matching data between the Emphasys Elite system of records to ensure the most overdue inspections are scheduled. 2. A bulk inspection process was implemented effective November 1, 2024. Through this process, all units for a particular PBV site are scheduled for their annual inspections in the same month each year. This ensures that all units are inspected annually. The scheduling process includes: a. Posting the bulk inspection schedule on the website. This is an annual schedule which identifies properties, property management, and the month the project will be inspected. b. Providing notice to the applicable site owner/manager of the inspection date and the units to be inspected. The notice will include information on how to prepare for the inspection, a request to have site staff accompany the inspector, and a reminder to notify residents so access can be gained even if no one is home. c. Sending individual inspection notices to the owner and participant for each scheduled inspection. For the PBV portfolio, staff will work directly with property management and developers to ensure access to units is continuously granted. Upcoming bulk inspections are also discussed on calls with owners. This allows for increased planning and respect for noticing timelines. Tenant-Based Program: • Review the report of outstanding HQS Inspections on a weekly basis. • Schedule outstanding HQS Inspections in order of aging date. • Conduct HQS Inspections prior to the anniversary date of previously completed inspection. • Running a monthly report of failed inspections and comparing them with future scheduled inspections to ensure that a second inspection has been scheduled. • Running a monthly report to identify units with two failed inspections to ensure all have been abated correctly. • Implement weekly monitoring to ensure all units are properly abated and lifted timely when units pass inspections and contracts are properly terminated after being in abatement for 180 days without a cure. The Authority has worked with Emphasys to identify the best ways to sort aged HQS inspections due and generate/schedule in bulk, as well as maximize the Inspector’s workday by routing the tenantbased units in a way that flows in a clear and orderly manner. Similar to the handling of delinquent annual reexaminations, the Authority is checking the data in PIC with the system of records and processing 50058 corrections where inspections have been completed but rejected in PIC due to out of sequence effective dates and any other fatal errors that require corrective action. The procedures for the project-based and tenant-based programs are already in effect, and the backlog of inspections has been substantially reduced as illustrated by a reporting rate of 99% for SEMAP Indicator 12 annual HQS inspections as of May 31, 2025. Monthly performance reports are also reviewed by management to ensure inspection timeliness is maintained. Anticipated Implementation Date September 30, 2025 Name(s) and Title(s) of Contact Person(s) Responsible for Correction Action HCV Contractors Kendra Crawford, Director of Housing Operations

View Audit 360716

Finding 569051 (2024-003)

Significant Deficiency 2024

Town of Greenwich, Connecticut

CT

Reporting Significant Deficiency § 200.512

2024-003- Significant Deficiency, Data Collection Form (Repeat Finding 2023-003) Audit Finding; The Town did not submit the 2024 or 2023 federal reporting packages with the Federal Audit Clearinghouse within the required timeline of either 30 days after receipt of the auditor’s reports or nine (9) m...

2024-003- Significant Deficiency, Data Collection Form (Repeat Finding 2023-003) Audit Finding; The Town did not submit the 2024 or 2023 federal reporting packages with the Federal Audit Clearinghouse within the required timeline of either 30 days after receipt of the auditor’s reports or nine (9) months after the end of the Town’s fiscal year as required by CFR 200.512(a)(1). Corrective Action Taken: We agree with this audit finding, resulting from turnover at the BOE. The delays should not reoccur in the future. Name and Phone # of Person Responsible for Implementation Mr. Peter Mynarski, Comptroller 203-622-2226

View Audit 360711

Finding 569050 (2024-003)

Significant Deficiency 2024

Rape Crisis Center of Collin County

TX

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Cash Management

Finding Number: 2024-003: Allowable Costs – 3 of the 25 payroll transactions tested, the time and effort charged to the grant did not agree to the employee’s timesheet. The amount of time charged to the grant was greater than what was approved to be charged to the grant per the employee’s timesheet ...

Finding Number: 2024-003: Allowable Costs – 3 of the 25 payroll transactions tested, the time and effort charged to the grant did not agree to the employee’s timesheet. The amount of time charged to the grant was greater than what was approved to be charged to the grant per the employee’s timesheet hours and grant budget allocations, and additional fringe benefits were charged that were not consistent with the other charges to the grant. Planned Corrective Action: The Turning Point has enhanced training on completing Grant Activity Reports through individualized one-on-one training during NEO and posted how to videos for continued education. The Grant Activity Reports will be audited monthly by comparing the hours to what was billed to grants and the Allocation Spreadsheet. Completion Date: October 1, 2024 Responsible Contact Person: Tana Rice, Director of Finance

View Audit 360710

Finding 569048 (2024-001)

Significant Deficiency 2024

Rape Crisis Center of Collin County

TX

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness

Finding Number: 2024-001: Allowable Costs – 2 out of the 38 samples tested included charges that were either unsupported or refunded back to the Organization and not corrected to return those funds to the grantor. Planned Corrective Action: The Turning Point has updated policies that include a proce...

Finding Number: 2024-001: Allowable Costs – 2 out of the 38 samples tested included charges that were either unsupported or refunded back to the Organization and not corrected to return those funds to the grantor. Planned Corrective Action: The Turning Point has updated policies that include a process for managing refunds and crediting them back to grants. We also updated our Expense Reimbursement and Credit Card policies in 2024 to simplify our payment process which includes both the Finance Director and Executive Director checking all expenses have the proper documentation prior to paying the statements/invoices and submitting to payors (funders) for reimbursement. Completion Date: June 1, 2025 Responsible Contact Person: Tana Rice, Director of Finance

View Audit 360710

Finding 569036 (2024-002)

Significant Deficiency 2024

Galveston Bay Foundation, Inc.

TX

Subrecipient Monitoring Significant Deficiency § 200.331

Finding #2024-002 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Environmental Protection Agency, Assistance Listing #66.456, National Estuary program, Passed through Texas Commission on Environmental Quality: Contract period: 09/01/23 – 08/31/25, Contract numb...

Finding #2024-002 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Environmental Protection Agency, Assistance Listing #66.456, National Estuary program, Passed through Texas Commission on Environmental Quality: Contract period: 09/01/23 – 08/31/25, Contract number: 582-24-50165. Condition and context: We reviewed one of the two subrecipient awards for the required information described in the criteria above and noted such provisions were not included in the subrecipient agreement. Recommendation: Policies and procedures should be implemented to ensure all required information is included in the subrecipient agreement before issuance. Planned corrective action: Management agrees with the finding and would like to provide additional context to this situation. This agreement occurred during the early implementation phase of a multi-year grant in 2023, when the Foundation was still establishing internal processes for managing subawards under federal funding requirements. At the time of this transaction: The federal award had not yet been formally executed, though the federal agency provided authorization to begin incurring expenses. The subrecipient, a partner organization, drafted and issued the agreement using their standard contract template. Since that time, the Foundation has updated its procedures for subsequent subrecipient agreements to include the required Uniform Guidance information as outlined in 2 CFR §200.331(a). This was an isolated incident during a transitional period, and management is confident that current processes address this issue. To prevent recurrence, the Foundation will: Continue to follow updated subrecipient agreement templates, which include all required award and federal compliance language. Provide refresher training to staff involved in grant and contract administration on subrecipient vs. vendor classifications and associated federal requirements. Perform an annual compliance review of all subrecipient agreements to ensure ongoing adherence. Responsible officer: Dawn Asbury, Controller. Estimated completion date: July 31, 2025.

View Audit 360694

Finding 569032 (2024-002)

Significant Deficiency 2024

Gloversville Housing Authority

RI

HUD Housing Programs Internal Control / Segregation of Duties Subrecipient Monitoring

2024-002 – REPORTING Other Matter/Significant Deficiency Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the year-end financial statements will be prepared and submitted timely and formalized guidelines for fina...

2024-002 – REPORTING Other Matter/Significant Deficiency Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the year-end financial statements will be prepared and submitted timely and formalized guidelines for financial reporting will be created. New controls over financial close process will ensure more accurate financial reporting prior to the audit. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director

View Audit 360687

Finding 569027 (2024-001)

Significant Deficiency 2024

Rio Grande Headwaters Land Trust

CO

Subrecipient Monitoring Reporting Significant Deficiency

Finding 2024-001: North American Wetlands Conservation Fund Assistance Listing Number: 15.623 U.S. Department of Interior Pass-through: N/A Compliance Requirement: Reporting Grant No.: N/A Type of finding: Internal Control Over Complian...

Finding 2024-001: North American Wetlands Conservation Fund Assistance Listing Number: 15.623 U.S. Department of Interior Pass-through: N/A Compliance Requirement: Reporting Grant No.: N/A Type of finding: Internal Control Over Compliance (significant deficiency) and Compliance (noncompliance) Recommendation: The Organization should strengthen its internal with adopted policies and procedures that include evaluation of grant terms and conditions to ensure compliance with reporting requirements. Action Taken: FFATA reports were completed in May 2025 for any funds withdrawn for the years 2024 and 2025 and the Trust is awaiting guidance on reporting retroactively for previous years. Rio Grande Headwaters Land Trust added a step to our ASAP.gov withdrawal instructions: Ensure to file a FFATA report on Sam.gov immediately if the funds drawn down are pass through (or schedule a reminder on your calendar for prior to the end of the next calendar month). The Executive Director is now the sole grant reviewer and signer on grant agreements, as well as the only ASAP.gov and SAM.gov admin which will allow the Land Trust to ensure compliance with reporting requirements in the future. If there are questions regarding this plan, please call the responsible party listed below. Sincerely yours, Laura Cusick Executive Director Rio Grande Headwaters Land Trust

View Audit 360669

Finding 569026 (2024-001)

Significant Deficiency 2024

Gardner Housing Authority

MA

HUD Housing Programs Eligibility Significant Deficiency

Planned Implementation Date of Corrective Action: July 2025 Person Responsible for Correctove Action: Krishonna Murray, Executive Director I. 2024-001 Eligibility Rent Calculation Other Matter/Significant Deficiency The Authority had instances of missing income verifcation. Gardner Housing Au...

Planned Implementation Date of Corrective Action: July 2025 Person Responsible for Correctove Action: Krishonna Murray, Executive Director I. 2024-001 Eligibility Rent Calculation Other Matter/Significant Deficiency The Authority had instances of missing income verifcation. Gardner Housing Authority has establised a system of internal control over the participant recertification process that meets HUD's requirements. Seven (7) to ten (10) files will be reviewed fiscally for quality assurance.

View Audit 360667

Finding 568950 (2024-002)

Significant Deficiency 2024

Universities Space Research Association

MD

Significant Deficiency Internal Control / Segregation of Duties § 200.308

The Company acknowledges the importance of accurately documenting key personnel requirements in support of federal contract compliance. The audit noted one contract with two projects where the individual listed as key personnel did not match the most current contract documentation. However, internal...

The Company acknowledges the importance of accurately documenting key personnel requirements in support of federal contract compliance. The audit noted one contract with two projects where the individual listed as key personnel did not match the most current contract documentation. However, internal “load sheets” and program communications consistently reflected the correct personnel assignments, and there was no impact on contract performance or deliverables. Given the isolated nature of these discrepancies and their lack of effect on program execution or financial reporting, the Company does not consider this matter to be material. Nonetheless, to strengthen internal controls, the Contracts Department now records and maintains all key personnel data directly in Costpoint. Additionally, the Controller performs a quarterly internal review of these records to verify accuracy and completeness. These measures provide added assurance that the Company remains fully compliant with federal award requirements. Director of Contracts/Elena Einstein now oversees this control which was put into place as of April 2025.Notwithstanding these findings, management is confident that the accompanying financial statements present fairly, in all material respects, the Company’s financial position for the fiscal year ended September 30, 2024.

View Audit 360636

Finding 568861 (2024-003)

Significant Deficiency 2024

Town of Cleveland

AL

Subrecipient Monitoring Cash Management Significant Deficiency

The Mayor's Office is fully committed to addressing the audit finding and the requirement per the grant agreement to develop and implement a fiscal sustainability plan as of 06/10/2025 on any futhter awarded funds. The corrective actions outlined in this plan reflect the importance of prudent financ...

The Mayor's Office is fully committed to addressing the audit finding and the requirement per the grant agreement to develop and implement a fiscal sustainability plan as of 06/10/2025 on any futhter awarded funds. The corrective actions outlined in this plan reflect the importance of prudent financial management and forward-thinking strategies to safeguard the financial future of our community. Anticipated Completion Date: 6/10/2025 James A. Sullivan, Mayor.

View Audit 360598

Finding 568859 (2024-002)

Significant Deficiency 2024

Town of Cleveland

AL

Cash Management Subrecipient Monitoring Significant Deficiency § 200.303 § 200.305

Town will no longer be holding invoices until ARPA funding is received but will follow the reimbursement guidelines per the grant agreement. April 30th 2025 anticipated completion date. James A. Sullivan Mayor

View Audit 360598

Finding 568222 (2024-002)

Significant Deficiency 2024

National Indigenous Women's Resource Center, Inc.

MT

Subrecipient Monitoring Reporting Significant Deficiency

Internal Control over compliance - reporting. Non-compliance with reporting compliance requirements. Recommendation: We recommend the Center to carefully review grant agreements and ensure that grants personnel are familiar with the grant compliance requitements for reporting. We slo recommend the C...

Internal Control over compliance - reporting. Non-compliance with reporting compliance requirements. Recommendation: We recommend the Center to carefully review grant agreements and ensure that grants personnel are familiar with the grant compliance requitements for reporting. We slo recommend the Center to update its grant policies and procedures for the FFATA reporting requirement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: All grant agreements will be carefully reviewed for compliance requirements for reporting. The Center has taken steps to familiarize applicacle staff with the compliance reports for FFATA reporting, and progress has been made in the requirement to report subawards granted under FFATA reporting. We will also update our grants policies and procedures to specifically include a section for FFATA reporting of subawards.

View Audit 360498

Finding 568218 (2024-003)

Significant Deficiency 2024

Northwest Indian Fisheries Commission

WA

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness § 200.303 § 200.329

Person(s) responsible for corrective action: Todd Bolster, Director of Administration and Dietrich Schmitt, Grants Program Manager. Management’s Response/Corrective Action Plan: For this tribal pass-through program, narrative, non-financial progress reports are collected from tribes, reviewed and...

Person(s) responsible for corrective action: Todd Bolster, Director of Administration and Dietrich Schmitt, Grants Program Manager. Management’s Response/Corrective Action Plan: For this tribal pass-through program, narrative, non-financial progress reports are collected from tribes, reviewed and approved by the NWIFC Grants Program Manager and submitted to PSFMC. Effective immediately, the NWIFC grants program manager will increase internal controls by including documentation of internal review and approval prior to progress reports being submitted to PSMFC. Anticipated completion date: July 2025.

View Audit 360492

Finding 568215 (2024-002)

Significant Deficiency 2024

Survivors of Torture, International

CA

Cash Management Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Finding 2024-002 Condition: During the auditors’ walkthroughs of the cash draw process, the Organization indicated that there is a lack of evidence supporting preparation and review of federal drawdowns. Corrective action plan: Management agrees with the recommendation and will establish a written ...

Finding 2024-002 Condition: During the auditors’ walkthroughs of the cash draw process, the Organization indicated that there is a lack of evidence supporting preparation and review of federal drawdowns. Corrective action plan: Management agrees with the recommendation and will establish a written policy and implement a documented process for the preparation and review of federal drawdowns, including clear evidence of review such as signoffs or electronic approvals. Responsible Individual: Andres Chavarro, Finance Manager Planned Completion date: 07/01/2025

View Audit 360483

Finding 568153 (2024-004)

Significant Deficiency 2024

The Salvation Army Northwest Division

WA

Internal Control / Segregation of Duties Reporting Significant Deficiency

The Division will enhance controls to ensure timely submission of reports and that there is segregation of duties between the report preparer and reviewer. Reports will be reviewed prior to submission and the review and submission of reports to granting agencies will be documented. A schedule of re...

The Division will enhance controls to ensure timely submission of reports and that there is segregation of duties between the report preparer and reviewer. Reports will be reviewed prior to submission and the review and submission of reports to granting agencies will be documented. A schedule of reports will be added to the TSAMM during the review and approval of new contracts. We will also work with our funders to extend reporting due dates. Anticipated Completion Date: 12/31/25. Responsible Contact Person: Yohannes Gedlu, NW Divisional Finance Director & Julie Luft, NW Social Services Director

View Audit 360458

Finding 568135 (2024-003)

Significant Deficiency 2024

The Salvation Army Northwest Division

WA

Equipment & Real Property Management Internal Control / Segregation of Duties Special Tests & Provisions

The Division will ensure evidence of review is maintained for the inventory worksheets. This was also reviewed during the NW Division’s Social Service conference in April 2025. Anticipated Completion Date: 10/1/25. Responsible Contact Person: Julie Luft, NW Social Services Director

View Audit 360458

Finding 568083 (2024-001)

Significant Deficiency 2024

The Salvation Army Northwest Division

WA

Internal Control / Segregation of Duties Reporting Significant Deficiency

The Division will enhance controls to ensure timely submission of reports and that there is segregation of duties between the report preparer and reviewer. Reports will be reviewed prior to submission and the review and submission of reports to granting agencies will be documented. A schedule of re...

The Division will enhance controls to ensure timely submission of reports and that there is segregation of duties between the report preparer and reviewer. Reports will be reviewed prior to submission and the review and submission of reports to granting agencies will be documented. A schedule of reports will be added to the TSAMM during the review and approval of new contracts. We will also work with our funders to extend reporting due dates. Anticipated Completion Date: 12/31/25. Responsible Contact Person: Yohannes Gedlu, NW Divisional Finance Director & Julie Luft, NW Social Services Director

View Audit 360458

Finding 568062 (2024-001)

Significant Deficiency 2024

Bastrop County Women's Shelter, Inc. Dba Family Crisis Center

TX

Cash Management Reporting Significant Deficiency § 200.303

1) Effective 3/7/25, reports and requests for reimbursements are being reviewed, signed and dated by the Executive Director prior to submission to ensure the reports and requests for reimbursements are not incomplete or inaccurate; and 2) Financial Policy addressing the Deficiency in Internal Contro...

1) Effective 3/7/25, reports and requests for reimbursements are being reviewed, signed and dated by the Executive Director prior to submission to ensure the reports and requests for reimbursements are not incomplete or inaccurate; and 2) Financial Policy addressing the Deficiency in Internal Controls over Compliance were already in place during the audit period. These policies were reviewed by the Board of Directors on 6/11/25 and found to align with the best practices and compliance requirements. Following the audit, we have also taken steps to reinforce the adherence and ensure consistent implementation across all relevant areas. Responsible Parties: Brandi Senters, Finance Director, will be responsible for implementation, with oversight from Interim Executive Director, Bernie Jackson.

View Audit 360432

Finding 568028 (2024-004)

Significant Deficiency 2024

Catholic Medical Mission Board, Inc.

NY

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Management acknowledges the importance of maintaining accessible and complete documentation to support all transactions charged to federal grants. The inability to provide the requested approvals for certain transactions was due to the challenging security conditions in some country offices during t...

Management acknowledges the importance of maintaining accessible and complete documentation to support all transactions charged to federal grants. The inability to provide the requested approvals for certain transactions was due to the challenging security conditions in some country offices during the audit period. To strengthen documentation access and retention, the Organization has transitioned to NetSuite, where backup documentation for transactions is now stored centrally on the cloud and can be easily accessed by headquarters staff. This change enhances our ability to ensure timely review, approval, and audit readiness, regardless of field conditions. We remain committed to continuous improvement of our internal controls and documentation practices. Responsible Person: Country Finance Directors

View Audit 360404

Finding 568024 (2024-002)

Significant Deficiency 2024

MacOn County Samaritan Memorial Hospital

MO

Significant Deficiency Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

FINDINGS— FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL PROGRAMS DEPARTMENT OF AGRICULTURE 2024 – 002 Community Facilities Loans and Grants Recommendation: Management should continue to focus on making operational improvements to achieve the minimum level of Historical Debt Service Coverage of 1.25...

FINDINGS— FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL PROGRAMS DEPARTMENT OF AGRICULTURE 2024 – 002 Community Facilities Loans and Grants Recommendation: Management should continue to focus on making operational improvements to achieve the minimum level of Historical Debt Service Coverage of 1.25, as required. Action taken in response to finding: The Hospital will continue to make operational improvements to achieve the minimum level of Historical Debt Service Coverage of 1.25 . Name of the contact person responsible for corrective action: Carli Taylor, Chief Financial Officer. Planned completion date for corrective action plan: December 31, 2025 If the Department of Health and Human Services has questions regarding this plan, please call Carli Taylor, Chief Financial Officer at 660.385.8716 .

View Audit 360393

Finding 567994 (2024-001)

Significant Deficiency 2024

Bellflower Oak Street Manor 122-Ee105

CA

HUD Housing Programs Significant Deficiency Special Tests & Provisions

CORRECTIVE ACTION PLAN Name of auditee: Bellflower Oak Street Manor Name of audit firm: Propp Christensen Caniglia LLP Period covered by the audit: October 1, 2023 through September 30, 2024 CAP prepared by: Name: Sean Calendar Position: Director of Accounting Telephone: (916) 357-5300 Comments: Man...

CORRECTIVE ACTION PLAN Name of auditee: Bellflower Oak Street Manor Name of audit firm: Propp Christensen Caniglia LLP Period covered by the audit: October 1, 2023 through September 30, 2024 CAP prepared by: Name: Sean Calendar Position: Director of Accounting Telephone: (916) 357-5300 Comments: Management agrees with the 2024-001 finding. Actions: Management will implement policies and procedures to ensure the monthly deposit to the replacement reserve is made in accordance with HUD regulations. Additionally, management will fund $19,824 of additional reserve deposits to make the account whole; $9,912 for the current period’s unfunded deposits and an additional $9,912 for unfunded deposits from prior period, as reported in finding 2023-01.

View Audit 360334

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